The present invention relates to administering prescription formulary data associated with various entities, and more particularly to providing customized or dynamically generated or adjusted formulary data based on the application of one or more rules to formulary data associated with the various entities.
As third-party payers have come to bear an increasing share of the cost of prescription drugs, they have sought ways to manage those costs and to save money through efficiencies in administering their programs. Third-party payers comprise employers and governments. Employees or patients also pay for prescriptions, directly in the form of co-payments or simply by paying the retail cost of prescription drugs and indirectly through their contributions to the cost of prescription drug coverage. (The term “payer,” as used herein, thus comprises employers, employees, and governments.)
Payers typically delegate administration of their payment systems to organizations called Pharmacy Benefit Managers (PBMs), which are intermediaries between payers on the one hand and patients and pharmacies on the other. Payers engage PBMs to administer their plans and to handle billing and payment.
To help control costs, payers sometimes limit the drugs that they will pay for. With the help of the PBMs, payers create lists of the medications that a managed health (or prescription drug) plan will pay for and the amounts that they will pay for each one. The lists may also include information about alternatives to unlisted drugs. In either case, such a list is called a formulary.
PBMs, in conjunction with payers, provide formularies to payers and to information and prescription aggregators, which operate as third-party electronic sources of formulary information. Examples of information and prescription aggregators are organizations such as Medimedia and RxHub. RxHub, for example, is an organization created by PBMs to help control payers' expenses. It receives formulary data for numerous health plans and then makes these formularies available to third parties. The formularies provided by RxHub are currently updated weekly and represent a substantial portion of formularies available in the U.S.
There are other content aggregators as well, which obtain formulary data from PBMs and make it available to others. For example, the Council for Affordable Quality Healthcare (CAQH) has created standards for electronically publishing formulary information. CAQH-formatted information is available through RxHub. Some sources of formularies operate independently of information and prescription aggregators yet seek to make their formulary information available electronically as well.
There are thousands of payers, and each has its own formularies. Each payer typically has numerous plans, and each plan can have a unique formulary. There are thus thousands of plans and formularies.
A payer may cover drugs at different levels depending on the plan that covers a particular person. Within a plan, also, there are likely tiers of coverage: the plan participant may have to pay more or less for drugs depending on the tiers in which the drugs are. For example, a formulary may specify that the co-payment is ten dollars for generic drugs, but thirty dollars for branded ones.
Formulary information can affect decisions in the drug prescribing process. Current formularies are created based on drugs and coverage amounts specified in particular plans.
The coming of electronic prescribing, which is an application that helps prescribers use patient and formulary information when they create prescriptions electronically, has facilitated the use of information in formularies in the prescribing process. For example, a physician's selection of a medication in an electronic prescribing system loaded with the appropriate formularies triggers a query of the formulary to see if that specific medication is present. The query will provide the physician with information regarding the status of a medication as being on or off formulary. Depending on the data available, levels of co-payment can also be presented. The physician can write the prescription of the medication originally selected or can select a different medication.